Head and Neck Cancer Patients’ Quality of Life: Analysis of Three Instruments

Statement of the Problem: Head and neck cancer treatment has provided better cure and survival rates but the patient’s quality of life is still an issue. Purpose: To verify the correlation between the three most used instruments for evaluating the quality of life of head and neck cancer patients. Materials and Method: This cross-sectional study evaluated patients treated for head and neck cancer at the Mato Grosso Cancer Hospital, Cuiabá, MT, Brazil. The variables age, gender, cohabitation status, education, religion, smoking, ethnicity, tumor location and histological type and treatment modality were collected. The patients quality of life was assessed by the Functional Assessment of Cancer Therapy Quality of Life Measurement System (FACT-H&N), University of Washington Quality of Life Questionnaire (UW-QOL), and EORTC QLQ-C30/EORTC QLQ-H&N35 of the European Organization for Research and Treatment of Cancer. Results: The study population consisted of 33 individuals with a mean age of 63.42±11.25 years; 69.70% were males; 54.55% had no partner; 45.45% had only elementary education; 87.9% followed a religion; 84.38% were smokers and 87.50% alcoholics. Squamous cell carcinoma responded for 78.79% of the cases and palate/oropharynx and mouth floor (21.21% each) were the most affected sites. All patients underwent radiotherapy, 90.91% chemotherapy and 63.64% surgery. On the analysis of quality of life, shoulder (UW-QOL), social performance (EORTC QLQ-C30/QLQ-H&N35) and overall well-being (FACT-H&N) had the highest scores while saliva (UW-QOL), nausea and vomiting (EORTC QLQ-C30/QLQ-H&N35) and emotional well-being (FACT-H&N) had the lowest scores. A positive correlation was found between the questionnaires for the patient's overall quality of life and the domains Pain, Appearan-ce, Activity, Deglutition, Chewing, Speech, Taste, Saliva, Mood and Anxiety. Conclusion: Given the correlation between the questionnaires, the selection of the instrument for future research involving head and neck cancer patients’ quality of life should consider the specific aspects to be evaluated.


Introduction
The term "head and neck cancer" is defined by anatomical and topographic bases to describe malignant upper aerodigestive tract tumors, including oral cavity, pharynx and larynx [1]. It is the nineth most common malignant neoplasm in the world, with high incidence, prevalence and mortality [2]. Despite cancer treatment has achieved better results in recent decades, providing a significant increase in patient survival [3], head and neck cancer patients, as well as having a life-threatening disease, have to deal with the impact of their treatment on functional and aesthetic aspects. The affected region is the anatomical site of basic functions, such as speech, swallowing, hearing and breathing, which are of vital importance for an individual, besides being related to social interaction [4][5]. Thus, researchers have given greater attention to the assessment of quality of life (QOL) of these patients [3].
To evaluate the quality of life of patients with cancer is important to be able to understand the impact of the disease and its treatment on the daily routine of the patient and to improve the protocol of care with more comprehensive clinical, social and rehabilitation support measures [6]. Quality of life studies in head and neck cancer patients in chemotherapeutic and radiotherapeutic treatment have evaluated the side effects of treatment and assisted in the planning of interventions to reduce both physical and psychological stress for better patient rehabilitation [7][8]. As patient survival has increased and as the disease and its treatment impact on their quality of life, it was observed the need to study the quality of life among these patients [3]. The assessment of quality of life enables health professionals to understand how patients experience the evolution of the disease, the impact of the disease on their life, the sequelae of the treatment and relapse of the disease, as well as the effectiveness and consequences of the treatments and of the care offered [6]. items, a high score indicates poorer quality of life [11].
The data obtained corresponds to the patient's condition during the last week [12].
As the questionnaires present their particularities,

Characteristics of the population
The study population consisted of patients who met the following criteria: they were diagnosed with cancer in the head and neck region; have been undergoing antineoplastic treatment for cancer treatment and the treatment has been completed for at least six months.  (Table 1).
Afterwards, the correlation of the instruments was analyzed. To analyze if there was a correlation between the questionnaires, that is, the dimensions measured by the different instruments lead to the same conclusion, it was necessary to standardize the meaning of the scores.
The defined pattern was the higher the score, the higher  Score 0-144 0-100 0-100 scale, the score was inverted when the data was transcribed to the spreadsheet, so that the highest scores were equivalent to the best QOL.

Statistical analysis
The data of the questionnaires were manually

Results
The total study population consisted of 33    After analyzing the quality of life of the patients with each instrument, an analysis of the correlation of the instruments was performed ( Table 4). The overall score of the three questionnaires as well as the specific domains presented a statistically significant positive correlation.

Discussion
The mean age of the patients in this study was 63.42 years; the youngest was 41 years old and the oldest was 85 years old. Those are similar to previous studies that found the sixth decade of life as the main one in the diagnosis of head and neck cancer [16][17][18]. It is also similar to the population of the other studies from different parts of Brazil, whose mean age was 63.5 [18] and 61.1 years [19]. The population of this study was predominantly male (69.7%), also agreeing with previous studies with head and neck cancer patients in Mato Grosso, Brazil and other countries [15][16][17][18][19][20]. Regarding the presence of companion (45.5%), schooling (45.45% studied until elementary school) and religion (87.88% followed a religion), the profile of the patients in this study is also similar to previous studies conducted in Brazil [18,21]. Regarding the habits, 84.38% and 87.50% of the individuals used or still use tobacco and alcohol respectively. All individuals who use or used alcohol have the same behavior with tobacco. Almeida et al. [22] found a similar prevalence of these habits.
Smoking and alcoholism are considered important risk factors for the development of head and neck cancer and may interfere with the prognosis of cancer treatment [23].
Most of the patients (78.79%) presented a diagnosis of epidermoid carcinoma, which represents the most common histological type in head and neck neoplasms, especially in oral and oropharyngeal cancer [24][25]. It affects mainly males, older than 50 years, smokers and/ or alcoholics [26], as observed in this study.
The result is similar to that found by Dobrossy [24], 40% in the oral cavity, 25% in the larynx, 15% in the pharynx and the rest in the salivary and thyroid glands.
Yet, in an epidemiological study conducted from 1997 to 2000 in Santos, SP, Brazil, the tongue was the most frequent site, with 51.1% followed by the mouth floor with 25.5% [27]. In the work of Perez et al. [28], the area most affected by cancer was the floor of the mouth, with 317 patients (57.5%), followed by the oropharynx with 140 patients (25.3%) and palate and lips with 11 cases (6.5 %) each.
Of the 33 patients, 100% underwent radiotherapy, 90.19% also underwent adjuvant chemotherapy and 63.64% underwent surgery. The antineoplastic treatment is defined on the staging of the disease [29].
In the case of head and neck tumors, radiotherapy and surgery are the most recommended treatments [30].
Radiation therapy can be used with curative or palliative intent and the application schedule depends on the total dose calculated and the radiotherapist's evaluation [31].
The study population consisted of patients treated for head and neck cancer under follow-up, recruited for convenience. Convenience samples are common in the health area because they allow the researcher to select the subjects to which they have access, assuming that they can represent a universe [32]. All the research subjects were invited to complete the three quality of life questionnaires following the guidelines for completing each instrument [6,33].  [12].
The present study found a significant correlation be-tween the three instruments, so regardless of the questionnaire used, the same result in relation to quality of life is found either in the overall evaluation of the patient or in the evaluation of the specific domains of Pain, Appearance, Activity, Swallowing, Chewing, Speech, Taste, Saliva, Humor and Anxiety. Although they were the most used instruments to analyze the quality of life of this specific patient profile [34] and had been widely validated [42], no previous study was found that analyzed the correlation between the three instruments.
However, due to the broad characteristic of the quality of life and because it is subject to interferences of factors of different natures, there is still no instrument capable of fulfilling such task to analyze it completely [43]. Finally, given the increasing success rate of antineoplastic therapies and the consequent increase in patient survival [44], and the need to provide comprehensive and humanized care to these patients [45], it is suggested that the evaluation of QOL in patients with head and neck cancer be incorporated into clinical practice. That will assist health professionals in the decision-making process of treatment, sequelae control, institution of preventive measures and psychological orientation both to the patient and to their families. Given the correlation between the questionnaires and the particularities of each one, the selection of the instrument for future research involving patients with head and neck cancer should take into account the specific aspects that one wishes to evaluate.

Conclusion
Considering the studied population and the methodology used in this research, it is concluded that: • The socio-demographic profile, prevalence of location and histological type of head and neck cancer and the antineoplastic treatment given to the patients is similar to that of previous studies; • The UW-QOL, EORTC QLQ-C30/QLQ-H&N35 and FACT-H&N questionnaires presented a statistically significant correlation in the assessment of the patient's overall quality of life and in the specific domains Pain, Appearance, Activity, Swallowing, Chewing, Saliva, Humor and Anxiety.